Dr. Allan Horowitz, published newspaper article, The Liberal, Copyright May 8, 1991
If you have been a faithful reader of this column, you have been reading with interest the last few columns on decision-making in back surgery. One of the most common questions any chiropractor is asked by a patient who suffers from lower back pain is: “Will I need surgery?”
The only one who can answer with a degree of expertise is a competent, experienced surgeon who fully reviews all of the relevant findings.
Last week I discussed the factors which should be present if disc surgery is likely to be successful in relieving a patient’s back and leg pain. Today I will discuss the findings that, if present, indicate that this type of surgery might not be successful. Something else, other than surgery, should be considered when advising these patients on treatment for their disc problem.
If a patient has back pain, but not a significant amount of leg pain, the surgery might not be too helpful. (When a disc ‘bulges’, it hits the nerve which goes down the leg)
Grossly obese patients might be advised to try a different form of therapy, or at least lose some of their excess weight before considering surgery. Not only are they a higher risk for any type of surgical procedure, but the added weight they are carrying around is certainly putting more pressure on the disc. Just losing some weight might help decrease their pain enough that they won’t require surgery. Initially, the response to disc surgery of obese patients is about the same as that of non-obese patients, but the recurrence rate of pain is higher in the obese patients.
Nonorganic signs and symptoms. If the patient is complaining of things that don’t make any sense from an anatomical or physiological standpoint, it is best not to operate. If the patient complains that their entire leg is numb, instead of just the back or side of the leg, if they have weakness in their leg or hip that is not explainable by a typical disc herniation or if they have pain in other areas of their body that don’t “fit” with the rest of the clinical picture, it is best to avoid surgery until a more clear understanding is made of the clinical situation.
If the patient has a poor psychological background, the surgeon may not wish to complicate matters any more by attempting surgery. Just what a “poor psychological background” is is hard to define exactly. One book I read states that if the person has attempted suicide or is an alcoholic, or if a man has been off work for six months or a woman off work for 16 months, surgery should be reconsidered. I understand what this author is getting to, but I think some common sense must prevail. A suicide attempt 20 years earlier should not stop a surgeon from operating on a clear cut disc patient today. Alcoholics can have bad discs also. Being out of work for six months might mean a patient is lazy and unresponsive to treatment, but it also might mean he is having severe pain and deserves a chance at a healthier back. The point of “poor psychological background” is well taken, but we must be careful in passing judgement on patients because we don’t agree, understand or like some aspects of their life. Another point the author made is “hostility directed to employer, spouse or environment.” If all of the people who showed hostility to these were excluded from having back surgery, there would be many unemployed back surgeons.
Secondary Gain Pain. If a patient has something to gain from having their pain persist, it might just do that, despite attempts from the surgeon to help relieve the patient’s pain. If a patient is receiving money to be off work (disability insurance), being paid for their pain and suffering (as a result of a law suit from a car accident or a fall on someone’s icy steps), or because they are receiving extra love and attention from family members, there might be an innate, psychological barrier against them being free from pain, even if the surgery was successful. These patients can’t be excluded from surgery, but the surgeon must play detective and psychiatrist and try to guess what the outcome will be. Likewise, if the patient has a history of suing doctors for “treatment gone wrong,” a wise surgeon will always think twice about operating. He may think three or four times before operating, but again, just because a patient sued a doctor does not mean he/she isn’t entitled to proper care for the present problem. Extra care should be taken with these patients, because there are some people who would love the opportunity to take a bit of pain and stiffness that they have after the operation and pretend it is the end of the world. When the patient wakes up in the recovery room and the first person he calls is his lawyer, it usually means that the surgeon didn’t follow this last guideline carefully enough!